Wide Angle Youth Media is a non-profit that provides Baltimore youth with media education to

tell their own stories and become engaged with their communities. Wide Angle strives to make
media make a difference. For more information, visit www.wideanglemedia.org.
Enoch Pratt Free Library and Wide Angle Youth Medias

FREE One Day Only,
Summer
Photography
Workshops!
Join Wide Angle Youth Media for an exclusive youth photography workshop this summer! This one
day workshop will travel to local library branches and teach youth photography skills while they take
creative self portraits and discuss their community. There will even be free pizza!

Workshop Locat i ons and Dat es:
Pennsyl vani a Avenue Li brary Herri ng Run Li brary
Thursday, June 26
th
Thursday, July 3
rd

12-4pm, Ages 10-14 11am-3pm, Ages 10-14

Forest Park Li brary Pat t erson Park Li brary
Monday, July 21
st
Wednesday, July 23
rd

12:30-4:30pm 1pm-5pm, Ages 10-14

Rei st erst own Road Li brary Govans Li brary
Friday, July 25
th
Thursday, August 7
th

12pm-4pm, Ages 12-16 1pm-5pm, Ages 10-14

How t o appl y:
Please return the fully completed and signed application to
the library workshop branch or Wide Angle Youth Media via e-mail
(info@wideanglemedia.org), fax (410-752-7053), or mail (2601 N. Howard Street, St. 160).


This program is supported by the Enoch Pratt Free Library and The M&T Bank Charitable Foundation. Photographs taken
from the workshop may be displayed as part of our Youth Photography Traveling Exhibition in the 2015 Academic Year.
SUMMER PHOTOGRAPHY WORKSHOP STUDENT APPLICATION
PLEASE READ FORM CAREFULLY AND COMPLETE ALL FI ELDS.
!" $%& '()* (+$ ,&*-./%+-0 12*(-* 3(22 44567896:7;; %< *6=(/2 /+"%>?/@*(+A2*=*@/(B%<A
www.w|deang|emed|a.org


SUMMER PARTICIPANT INFORMATION (PLEASE PRINT CLEARLY)

llrsL name ___________________________ Mlddle lnlLlal ____________ LasL name_______________________________

nlckname ___________________________ Lmall Address ____________________________________________________

SLreeL Address _____________________________________________ ApL# ______________________________________

ClLy ______________________________________________________ SLaLe____________ Zlp ______________________

8lrLh uaLe (mm/dd/yy)___________________ Age _______________ Cender ____________________________________

School _______________________________________________________ Crade __________________________________

Pome hone ___________________________ Cell hone ____________________________________________________
ll (SLudenL lu) #______________________________________

ls Lhere anyLhlng else LhaL you would llke us Lo know abouL your chlld?___________________________________________

WhaL llbrary workshop locaLlon and daLe are you applylng for? (8equlred)_________________________________________

PARENT/GUARDIAN INFORMATION (PLEASE PRINT CLEARLY)

arenL/Cuardlan llrsL name ____________________________ arenL/Cuardlan LasL name___________________________

SLreeL Address _____________________________________________ ApL#________________________________________

ClLy ______________________________________________________ SLaLe____________ Zlp ________________________

8elaLlon Lo Chlld _________________ Pome hone ________________ Cell hone ___________________________________

L-mall ______ ___________________ 8esL Llme Lo reach you on Lhe phone? _______ MarlLal SLaLus __________________

!ob 1lLle: _____________________________ lace of LmploymenL _____________________________________________

EMERGENCY CONTACT INFORMATION (PLEASE PRINT CLEARLY)

Lmergency ConLacL name ________________________________________________________________________________

8elaLlonshlp Lo arLlclpanL _________________________________ Lmergency ConLacL's hone _______________________



MEDICAL RELEASE

l permlL my chlld Lo recelve emergency medlcal servlces lf necessary by a local hosplLal. l undersLand LhaL any medlcal expenses
wlll be dlrecLly bllled Lo my lnsurance company or me. Wlde Angle ?ouLh Medla and Lnoch raLL lree Llbrary are noL obllgaLed for
Lhe cosL, buL has my permlsslon Lo procure servlces for my chlld.

__________________________________________________ ________________________________________________
arent]Guard|an S|gnature Name of Insurance Company

|ease ||st any a||erg|es or med|ca| cond|t|ons we shou|d be aware of:____________________________________________

__________________________________________________ Date of |ast 1etanus Shot: ____________________________



SUMMER PHOTOGRAPHY WORKSHOP STUDENT APPLICATION
PLEASE READ FORM CAREFULLY AND COMPLETE ALL FI ELDS.
!" $%& '()* (+$ ,&*-./%+-0 12*(-* 3(22 44567896:7;; %< *6=(/2 /+"%>?/@*(+A2*=*@/(B%<A
www.w|deang|emed|a.org


As a parent or guard|an wou|d you? (Check a|| that app|y)
! uonaLe snacks for class ! AsslsL wlLh recrulLmenL ! PosL a Screenlng
! Chaperone a fleld Lrlp ! Make a flnanclal conLrlbuLlon ! CLher _________________

PLEASE CHECK YOUR ANSWERS TO THE FOLLOWING QUESTIONS:
1. Se|ect the race that best descr|bes your ch||d:
! Afrlcan Amerlcan ! Plspanlc
! Aslan ! Pawallan or
! Caucaslan aclflc lslander
! 8l-8aclal ! naLlve Amerlcan
! MulLl-8aclal ! CLher __________

2. Is your ch||d ent|t|ed to free or reduced-cost |unch?
(Clrcle one) ?es no


3. Is your ch||d current|y home|ess?
(Clrcle one) ?es no

4. Is your ch||d or your |mmed|ate fam||y current|y
rece|v|ng 1ANI*? CDEFGH I E*=1%<(<$ F--/-.(+3* .% G**@$ H(=/2/*-J
(Clrcle one) ?es no
S. Se|ect the status of your ch||d's fam||y:
! Slngle arenL - MoLher
! Slngle arenL - laLher
! 1wo arenL Pousehold
! Legal Cuardlan - 8elaLlve
! Legal Cuardlan - non 8elaLlve
! CLher - 8elaLlve
! CLher - non 8elaLlve
6. After c|ass, your ch||d may:
! Walk home alone
! 1ake publlc LransporLaLlon alone
! 8e plcked up only, please call _______________
7. Does your ch||d have any d|etary restr|ct|ons or needs?
! nuL Allergy
! kosher
! CLher _______________


Wi de Angl e Yout h Medi a Permi ssi on and Rel ease Form

I, ______________________________ g|ve my perm|ss|on for______________________________
(arent]Guard|an Name) (outh's Name)

parLlclpaLe ln any and all acLlvlLles of Wlde Angle ?ouLh Medla's hoLography Workshop aL Lhe Lnoch raLL lree Llbrary. l am aware LhaL my chlld wlll learn
how Lo use medla producLlon equlpmenL, and may have Lhelr own lmage and volce recorded ln Lhe process of learnlng how Lo produce medla messages,
whlch may be dlsLrlbuLed publlcly. l undersLand my chlld wlll be exposed Lo cerLaln rlsks LhaL by naLure and locaLlon of Lhese acLlvlLles cannoL be conLrolled. l
agree Lo release and forever dlscharge Wlde Angle ?ouLh Medla and Lhe Lnoch raLL lree Llbrary, Lhelr board of dlrecLors, volunLeers, and employees from
any and all llablllLy, and clalms ln any way connecLed wlLh Lhe mlnor's parLlclpaLlon ln Lhe hoLography Workshop. l undersLand LhaL my chlld wlll go on
supervlsed nelghborhood walks wlLhln a flve block radlus of Lhe Llbrary. Cn Lhese Lrlps my chlld wlll be phoLographed or conducLlng research for Lhelr vldeo
pro[ecL, and l glve permlsslon for Lhem Lo parLlclpaLe ln Lhls acLlvlLy.

l granL Wlde Angle ?ouLh Medla and Lhe Lnoch raLL lree Llbrary permlsslon Lo copyrlghL and use, reuse, publlsh, and re-publlsh Lhe lmage, volce, and
llkeness of my chlld, as well as any wrlLlng, drawlng, or oLher medla produced by my chlld, for lncluslon ln any medla produced by Wlde Angle ?ouLh Medla ,
and permlL Wlde Angle ?ouLh Medla and Lhe Lnoch raLL lree Llbrary Lo use maLerlals for sald medla for educaLlon, sales, promoLlon, and oLher relaLed
purpose ln prlnL, vldeo, on Lhe web, and all medla. l l walve any and all rlghLs Lo approve Lhe flnal producL or llmlL lLs dlsLrlbuLlon.




arenL/Cuardlan's rlnLed


arenL/Cuardlan's SlgnaLure uaLe